The British Columbia government needs to claw back some of the authority it has delegated to native agencies for aboriginal children, the province’s representative for children and youth says.

After a year-long investigation into the death of a four-month-old aboriginal boy, Mary Ellen Turpel-Lafond on Tuesday released a report on the case that reveals a chaotic and inadequate system that failed to protect an infant known to be at high risk.

Even before he was born, the boy’s alcohol-addicted mother was deemed unfit to care for him, and plans were made to place him with another relative. But as the mother flitted between on- and off-reserve homes with the baby, jurisdiction for the case bounced between a delegated aboriginal authority and the Ministry for Children and Family Development.

In his short life, the baby’s case was managed by 16 social workers who formulated 11 different plans for his protection. He lived in seven homes. The infant died of undetermined causes, lying in a wooden crib with no mattress, while under the care of a relative with an extensive criminal record and previous child protection issues.

“Case management was chaotic, and in many instances, there was no observable logic to decisions that were made,” Ms. Turpel-Lafond concluded in her report.

In an interview, she said the B.C. government has pushed the delegated authority system as a way to avoid responsibility rather than to provide the best care for vulnerable children.

“There is a strong element of, ‘you can administer your own misery, we’ve lost our commitment to watching over this,’” she said.

Since 1987, the province has been handing off responsibility for aboriginal child welfare to band agencies. Today, almost half of aboriginal children in care are managed by a band agency.

Bev Clifton-Percival, an executive of the First Nations Child & Family Wellness Council, endorsed the report, saying collaboration between band agencies and the province must be improved to ensure vulnerable children are protected.

“There should be seamless service delivery and accountability for all,” Ms. Clifton-Percival said, adding that this means putting the child’s needs first rather than worrying about jurisdictional claims. “We need to get a grip on this if we are going to make a fundamental change to care for vulnerable children.”

Ms. Turpel-Lafond said the agencies need more accountability – they should be required to report publicly on their work – while the province must ensure that its regional directors of child welfare are held responsible for the delegated agencies.

She does not identify the child or even the community in her report; however, she said the death, in April of 2007, is part of a larger, disturbing pattern in which the child-welfare system for thousands of aboriginal children is not seamlessly blended with the broader provincial one.

The cause of the baby’s death was classed as sudden infant death, but the investigation was muddied because first responders did not see the case as unusual. Police informed the coroner the death was not suspicious, and the coroner told physicians it was not necessary to come and view the body. Twenty-four hours passed before a second coroner saw a need to probe deeper and went to the home.

Mary McNeil, Minister for Children and Family Development, said on Tuesday the ministry is implementing changes in response to the child’s death. Where a family is likely to move back and forth between jurisdictions, staff in the region have been advised to assign joint workers to ensure that the interests of the children don’t get lost.